331 - Association of The First Timing of Transition from Invasive to Non-Invasive Ventilation and outcomes in neonates born less than 32 weeks’ gestational age

Publication Number: 331.3841

Min Yu, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China (People's Republic); jian yu, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China (People's Republic); Jie Yang, Fudan Children's Hospital, Shanghai, Shanghai, China (People's Republic); Yun Cao, Children's Hospital, Fudan University, Shanghai, PRC, Shanghai, Shanghai, China (People's Republic); Bin Sun, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China (People's Republic); Tao Pan, Children's Hospital Affiliated to Soochow University, Suzhou, Jiangsu, China (People's Republic)

Background: Although most very preterm infants (VPIs) born less than 32 weeks of gestation receive respiratory supports at admission in invasive ventilation (IV) or non-invasive ventilation (NIV), optimal timing of initial transition in ventilation modes specified by different disease statuses remains uncertain.

Objective: To explore the relationship between the timing of the first transition from IV to NIV and neonatal outcomes in VPIs.

Design/Methods: In this observational cohort study, we studied infants born between 2019 and 2023 using data from the Chinese Neonatal Network (CHNN). The study included VPIs born at gestational age (GA) of 25+0 to 31+6 weeks who required a transition from IV to NIV. Those who were discharged against medical advice, the first transition occurred later than 28 days and with severe congenital malformation were excluded. Exposures measures were the timing of the first transition, categorized into the following intervals, day 1-3, day 4-7, day 8-14, day 15-21 and day 22-28. The primary outcome was a composite outcome of mortality or any the following complications: severe retinopathy of prematurity (sROP), bronchopulmonary dysplasia (BPD),necrotizing enterocolitis(NEC) and late-onset sepsis (LOS). Generalized estimating equations (GEE) model with random effect were conducted to assess the association between the timing of the transition and the outcomes.Subgroup analysis were performed based on the presence of neonatal respiratory distress syndrome(RDS), patent ductus arteriosus(PDA), infection, systemic corticosteroids use, caffeine use, GA categories: GA 25-28 weeks and GA 29-31 weeks, IV categories including High frequency ventilation(HFV) only, conventional mechanical ventilation (CMV) only, and both HFV and CMV.

Results: A total of 9,406 preterm infants were included.The distribution of transition days was as follows: 1-3 days (38.9%), 4-7 days (36.3%), 8-14 days (17.3%), 15-21 days (4.9%) and 22-28 days (2.7%). Composite outcome occurred in 56.1% (n=5,273) of infants, ranging from 48.2% with timing at day 1-3 to 85.7% at day 22-28. BPD ranging from 38.8% to 82.5%. Severe ROP ranging from 5.5% to 23.9%. Hospital length of stay increased with delayed transition.Subgroup analysis showed that in infants receiving systemic corticosteroids and HFV or both HFV and CMV, the timing did not associated with the risk of composite outcome.

Conclusion(s): In VPIs, a delayed transition from IV to NIV is associated with an increased risk of adverse neonatal outcomes, particularly for sROP, and BPD, and prolonged hospital stay.

Table 1. Patient Characteristics in this Study
Abbreviation: CMV,conventional mechanical ventilation;CPAP, continuous positive airway pressure; HFV, high freguency oscillatory ventilation;hsPDA, haemodynamically significant patent ductus arteriosus; IQR, interquartile range; IV, invasive ventilation; IVH, intraventricular hemorrhage; LOS, late onset sepsis. NEC, necrotizing enterocolitis; NICU, neonatal intensive care unit; NRDS, neonatal respiratory distress syndrome; PVL, periventricular leukomalacia; SD, standard deviation; SGA, small for gestational age;TRIPIS, transport risk index of physiologic stability;
a hsPDA was defined as PDA treated in this study
bOther infections included ureaplasma urealyticum infection,central nervous system infection,lower respiratory tract infection,urinary system infection

Table 2. Timing of initial transition from invasive to non-invasive ventilation and neonatal outcomes
Abbreviation: OR, odd ratio; BPD, bronchopulmonary dysplasia; NEC, necrotizing enterocolitis; ROP, retinopathy of prematurity; IQR, interquartile range; LOS, late onset sepsis; NIV, non-invasive ventilation; NICU, neonatal intensive care unit.
a Adjusted for multiple pregnancy, gestational hypertension, antenatal antibiotic, antenatal steroids, cesarean delivery, gestational age, male, TRIPIS score, hsPDA，inborn, 5-min Apgar score <7, systemic corticosteroids, NRDS and caffeine. OR was applied to assess the association between exposures and binary variable outcome within logistic regression model, β was applied to assess the association between exposures and continuous variable outcome with linear regression model. Multilevel models were used with followed a 2-level hierarchical structure with participants (level 1) nested within NICUs (level 2).
b Composite outcome was defined as mortality or any of the following morbidities including BPD, severe ROP, NEC, and LOS.
c Death occurred after initial transition was the time-to-event outcome.
d BPD was defined according to Jenson NRN 2019 (Erik A Jensen, Kevin Dysart, Marie G Gantz, Scott McDonald, Nicolas A Bamat,  Sara B DeMauro,etc.The Diagnosis of Bronchopulmonary Dysplasia in Very Preterm Infants. An Evidence-based Approach .Am J Respir Crit Care Med, 2019 Sep 15;200(6):751-759. doi: 10.1164/rccm.201812-2348OC. )
e NEC occurred after initial transition was the time-to-event outcome.
f LOS occurred after initial transition was the time-to-event outcome.
g Reintubated before successful extubation was defined as reintubation within 7 days .
h Total ventilation included NIV and IV ventilation after initial transition.

Table 3. Subgroup analysis for the association between timing of initial transition from IV to NIV and composite outcome
a Adjusted for multiple pregnancy, gestational hypertension, antenatal antibiotic, antenatal steroids, cesarean delivery, gestational age, male, TRIPIS score, hsPDA，inborn, 5-min Apgar score <7, systemic corticosteroids, NRDS and caffeine.
b Composite outcome was defined as mortality or any of the following morbidities including BPD, severe ROP, NEC, and LOS.